BACKGROUND Comprehensive health assessment of the elderly in primary care will become a more important element of general practice as population aging proceeds and evidence of efficacy emerges. OBJECTIVE This article describes approaches to provision of health assessment in primary care based on the best available evidence. DISCUSSION Current best practice includes the use of structured health assessment protocols, an integrated multidisciplinary approach, targeting patient groups with intermediate levels of disability and handicap, in-home assessments and carefully structured follow up mechanisms.Len C Gray, Jonathan W Newbur

Gray, L.

Newbury, J.

Comprehensive health assessment of the elderly in primary care will become a more important element of general practice as population aging proceeds and evidence of efficacy emerges.This article describes approaches to provision of health assessment in primary care based on the best available evidence.Current best practice includes the use of structured health assessment protocols, an integrated multidisciplinary approach, targeting patient groups with intermediate levels of disability and handicap, in-home assessments and carefully structured follow up mechanisms

Gray, L. C.

Newbury, J. W.

University of Queensland eSpace

Health assessment of elderly patients

Adelaide Research &amp; Scholarship

Older patients are likely to represent an increasing pro-portion of the caseload of general practitioners into thefuture. The Australian population is currently aging withthe proportion of the population aged 65 years and overexpected to increase from 12% in 1996 to 15.9% in2016.1 More importantly, the proportion of very old peopleaged 80 years and older will increase from 2.6 to 3.9% ofthe population. This very old population has a high rate ofillness and disability with associated very high rates ofhospital and residential care utilisation.2,3 Of those very oldpeople living in the community, 46% of men and 59% ofwomen live alone 1.Very old people present some particular challenges toGPs. They often have multiple illnesses with associateddisability and dependence on others. Assessment ofmedical problems in isolation, without consideration offunctional abilities and their interaction with familymembers and their living environment, may yield sub-optimal results. Yet comprehensive assessment is difficultto achieve in traditional office practice. Many disabledolder people struggle to visit the office and the process ofevaluation is time consuming and potentially financiallyunrewarding in the standard fee for service arrangements. What is health assessment?In this article, we use the term ‘health assessment’ toreflect a structured approach to assessment of olderpeople using standardised protocols. Such approaches arenow widespread in specialist aged care practice and areused by individual practitioners and multidisciplinaryteams. The Enhanced Primary Care package (EPC), introducedin 1999 by the Commonwealth Department of Health andAged Care,4 included an example of such an approach –‘Health assessments for people age 75 years and over’(75+ health assessment) – as well as multidisciplinary careplans and case conferences. These were designed toprovide preventive care, facilitate joint work by GPs withnursing and allied health professionals, and to improveaccess to health services by the elderly and people withchronic conditions.Why conduct health assessments?Health assessments of older people have two importantfunctions:• the identification of clinical problems including dis-ability and psychosocial issues which may beoverlooked in less structured approaches. Typicalexamples include incontinence and cognitive impair-ment, and • the assessment of risk of preventable disorders andadverse events. Examples include the risk of fallrelated injury and malnutrition (see the articleMalnutrition in older people by Renuka Visvanathanpage 799 this issue). There are two important dimensions to prevention: • primary prevention through identification of risk andBACKGROUND Comprehensive healthassessment of the elderly in primary care willbecome a more important element of generalpractice as population aging proceeds andevidence of efficacy emerges.OBJECTIVE This article describes approaches toprovision of health assessment in primary carebased on the best available evidence.DISCUSSION Current best practice includes theuse of structured health assessment protocols, anintegrated multidisciplinary approach, targetingpatient groups with intermediate levels ofdisability and handicap, in-home assessments andcarefully structured follow up mechanisms.Health assessmentof elderly patientsLen C Gray, PhD, FRACP, isProfessor in GeriatricMedicine, University ofQueensland. Jonathan W Newbury,MD, FRACGP, isAssociate Professor,Spencer Gulf RuralHealth School,Department of GeneralPractice and RuralHealth, University ofAdelaide, SouthAustralia.Reprinted from Australian Family Physician Vol. 33, No. 10, October 2004 795Aging • THEMEtaking appropriate action, and • assessment of established illness and disability thatmay lead to subsequent deterioration or adverseevents.Two Australian randomised controlled trials (RCT) ofhealth assessment of the elderly have been completed.Newbury et al5 found no reduction in mortality nor thenumber of problems in the intervention group comparedto the control group. The intervention group did report animprovement in self rated health, reduction in depressionscore and reduced number of falls. The second trial,involving older veterans and war widows, suggested asmall positive effect of health assessments on quality oflife for those remaining in the community.6A meta regression analysis of preventive home visitsfor the elderly demonstrated a reduction in mortality inyounger study populations (mean age <80 vs. >80) andfunctional decline was reduced in populations with lowermortality rates.7 Stuck et al7 also found decreased func-tional decline and decreased nursing home admissions instudies employing a multidimensional assessment com-bined with regular home visits to follow up problems. Thisretrospective analysis does not necessarily indicate whatintervention is useful among the very old portion of the 75years and over population, or in the subset of the popula-tion with a higher mortality rate.To achieve these desirable outcomes (ie. identificationof clinical problems and assessment of risk of preventabledisorders) requires the multidimensional assessment of astandardised protocol combined with the rigorous followup process of a care plan. Stuck et al8 concluded theseresults should drive policy in countries where preventivehome visit programs for the elderly exist (Australia, Britainand Denmark).Which patients should be assessed? Comprehensive health assessments are time consumingand therefore expensive. In general, intensive interven-tions should be targeted to those patients with complexproblems that are likely to benefit from the process.Targeting in specialist aged care practice, particularly inthe hospital setting, has been associated with more effec-tive use of practitioner time and other resources. The high prevalence of illness and disability in the veryold underpins the choice of the 75+ health assessment.Activities of daily living (ADL) instruments have beenextensively used to assess function in the elderly. Thebasic ADL instrument consists of 10 items includingbathing, dressing, walking and continence.9 The basic ADLinstrument was designed to assess the chronically illelderly and only captures disability at a severe level. Theinstrumental ADL instrument measures higher functionsand consists of eight items including transport, shoppingand housekeeping.10However, evidence does not uniformly support thetargeting of 75+ health assessments to the frailelderly.11–13 Inclusion of relatively independent very oldpeople may attenuate the benefits. Studies that haveexcluded the more independent elderly have reportedpositive results.14,15 Bula et al16 performed a secondaryanalysis of a previous RCT,17 and found health assess-ment improved functional status in the subset with onlyinstrumental ADL impairment more than in the entirestudy population. These studies raise the possibility that the best func-tioning elderly do not benefit from a 75+ healthassessment as their functional impairments are not signifi-cant enough to measure an improvement after theassessment. This is consistent with the opinion of someAustralian GPs who are sceptical about the benefits of75+ health assessments for their patients. On the otherhand, those who have very poor function may not benefitbecause they are too disabled to be assisted by an annualassessment process and are already on the ‘slipperyslope’ to nursing home admission. Mechanisms for conducting an assessmentThe 75+ health assessment enables GPs to undertake anin-depth assessment of patients aged 75 years and over inthe context of their social and physical environment withthe aim of minimising potential health risks and improvinghealth outcomes. The Medicare Benefits Scheduledescribes the assessment as including medical, func-tional, psychological, and social/environmentcomponents.18 Data collection at home can be undertakenon behalf of the GP by nursing or allied health staff andreviewed by the GP later with the patient. Theseapproaches are underpinned by evidence from trials ofassessment processes. The 75+ health assessment is one of numerousmethods developed for assessment of frail, older people.A comprehensive review of such methods was con-ducted recently in New Zealand as a preliminary step todevelopment of a standardised approach in that country.19An Italian study14 produced significant benefits using theinterRAI home care assessment tool that is now in wide-spread international use.20 Some Australian services haveadopted screening (‘INI’ [initial needs identification]) andassessment (‘ONI’ [ongoing needs identification]) tools.Useful guides on ‘How to do a 75+ health assess-Theme: Health assessment of elderly patients796Reprinted from Australian Family Physician Vol. 33, No. 10, October 2004ment’ using standardised assessment protocols havebeen previously published in Australian Family Physician21and in a recent Australian geriatrics textbook.22 Ideally, theassessment should be conducted in the patient’s usualliving environment, and if there is any degree of depen-dence on others or evidence of cognitive impairment, inassociation with a close relative or friend. While the pro-cedure can be conducted by a GP alone, there may beadvantages in conducting the process in partnership withanother health professional. Introduction of nursing orallied health expertise into the process may result in amore rounded evaluation, increase the efficiency of theprocess and initiate ongoing cooperativecommunity/allied health service provision.RecommendationsThe following recommendations are broadly based on ourfield experience and the evidence presented in this article.It is suggested that GPs:• target health assessments – particularly to olderpeople with mild to moderate disability• develop a screening strategy to identify these patientsin the practice. Consider a file review of all existingvery old patients who have not already been assessed.(Computerised prescribing packages will report a list ofall patients over a specified age)• where possible, work with existing community servicestaff to conduct health assessments. Alternativelyengage appropriately trained practice nurses to supportthe process • develop a multidisciplinary care plan. Aim for an inte-grated approach with other services to promote sharingof assessment information and avoid duplication• include a home assessment in the protocol withregular reviews for high risk individuals• use specialist geriatric assessment services forpatients with very complex problems, particularlywhere situations are unstable.Conflict of interest: none.References1. Australian Institute of Health and Welfare. Older Australia at aglance. In: Gibson D, Benham C, Racic L, eds. Canberra: AIHW,1999.2. Australian Institute of Health and Welfare. Australian hospitalstatistics 2000–2001. AIHW cat no. HSE 20. Canberra: AIHW,2002.3. Australian Institute of Health and Welfare. Residential aged careservices in Australia 2000–2001: a statistical overview.Canberra: AIHW, 2002.4. Commonwealth Department of Health and Aged Care. MedicareBenefit Schedule Book. November 1999 edn. Canberra:Commonwealth Department of Health and Aged Care, 1999.5. Newbury J, Marley J, Beilby J. A randomised controlled trial ofthe outcome of health assessment of people aged 75 years andover. Med J Aust 2001;175:104–107.6. Byles J, Tavener M, O’Connell R, et al. Randomised controlledtrial of health assessments for older Australian veterans and warwidows. Med J Aust 2004;181:186–190.7. Stuck A, Egger M, Hammer A, Minder C, Beck J. Home visits toprevent nursing home admission and functional decline inelderly people. J Am Med Assoc 2002;287:1022–1028.8. Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Homevisits to prevent nursing home admission and functionaldecline in elderly people: systematic review and meta-regres-sion analysis. JAMA 2002;287:1022–1028.9. Mahoney F, Barthel D. Functional evaluation: the Barthel Index.Md State Med J 1965;14:61–65.10. Lawton M, Brody E. Assessment of older people: self maintain-ing and instrumental activities of daily living. Gerontologist1969;9:179–186.11. Stuck A, Minder C, Peter-Wuest I, et al. A randomised trial of in-home visits for disability prevention in community dwellingolder people at low and high risk for nursing home admission.Arch Intern Med 2000;160:977–986.12. Byles J. A thorough going over: evidence for health assessmentsfor older persons. Aust N Z J Public Health 2000;24:117–123.13. Elkan R, Kendrick D, Dewey M, et al. Effectiveness of homebased support for older people: systematic review and meta-analysis. BMJ 2001;323:719–724.14. Bernabei R, Landi F, Gambassi G, et al. Randomised trial ofimpact of model of integrated care and case management forolder people living in the community. BMJ1998;316:1348–1351.15. van Rossum E, Frederiks C, Philipsen H, Portengen K, WiskerkeJ, Knipschild P. Effects of preventive home visits to elderlypeople. BMJ 1993;307:27–32.16. Bula C, Berod A, Stuck A, et al. Effectiveness of preventive in-home geriatric assessment in well functioning, communitydwelling older people: secondary analysis of a randomised trial.J Am Geriatr Soc 1999;47:389–395.17. Stuck A, Aronow H, Steiner A, et al. A trial of annual in-homecomprehensive geriatric assessments for elderly people livingin the community. N Engl J Med 1995;333:1184–1189.18. Medicare Benefit Schedule Book. November 2000 edn.Canberra: Department of Health and Aged Care, 2000.19. Martin JO, Martin IR. Assessment of community dwelling olderpeople in New Zealand: a review of comprehensive andoverview assessment tools. Available at: www.nzgg.org.nz/guide-lines/0030/Final_Report_tools_review.pdf.20. Hirdes JP, Fries BE, Morris JN, et al. Integrated health informa-tion systems based on the RAI/MDS series of instruments.Health Manage Forum 1999;12:30–40.21. Newbury J, Marley J. 75+ health assessments. Aust FamPhysician 2001;30:82–87.22. Ratniake R, ed. Textbook of geriatric medicine. 1st edn.McGraw Hill, 2002.Theme: Health assessment of elderly patientsReprinted from Australian Family Physician Vol. 33, No. 10, October 2004 797Email: lgray@soms.uq.edu.au AFP

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Health assessment of elderly patients

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University of Queensland eSpace

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Health assessment of elderly patients

Abstract

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Adelaide Research & Scholarship